Valvular Heart Disease

Key Points

Patients with VHD may present with a heart murmur, symptoms, or incidental findings of valvular abnormalities on noninvasive testing.
The initial evaluation should include a detailed history and physical exam, ECG, chest x-ray, and transthoracic echocardiogram.
Decisions about treatment are based primarily on the presence or absence of symptoms, severity of VHD, and response of the ventricle to pressure or volume overload imposed by VHD.
VHD requires a multidisciplinary team and approach for its diagnosis and management.
Reasons for valve intervention are to improve symptoms, prolong survival, and reduce the risk of complications.
An evaluation of the surgical or interventional risk for each individual patient should be performed if intervention is indicated which includes a standard surgical risk score, along with consideration of comorbidites, frailty, and procedure specfic impediments.
Follow-up of patients with VHD is important to assess symptom status, provide patient education, and monitor disease severity, typically with periodic echocardiography.

Table 1. The Heart Valve Team

Recommendations	COR	LOE
Patients with severe VHD should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered.	I	C
Consultation with or referral to a Heart Valve Center of Excellence is reasonable when discussing treatment options for asymptomatic patients with severe VHD, patients who may benefit from valve repair versus valve replacement, or patients with multiple comorbidities for whom valve intervention is considered.	IIa	C

Evaluation

Table 2. Stages of Progression of VHD

Stage	Definition	Description
A	At risk	Patients with risk factors for development of VHD
B	Progressive	Patients with progressive VHD (mild-to-moderate severity and asymptomatic)
C	Asymptomatic severe	Asymptomatic patients who meet the criteria for severe VHD: C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle
D	Symptomatic severe	Patients who have developed symptoms as a result of VHD

Table 3. Risk Assessment Combining STS Risk Estimate, Frailty, Major Organ System Dysfunction, and Procedure-Specific Impediments

	Low Risk (Must Meet ALL Criteria in This Column)	Intermediate Risk (Any 1 Criterion in This Column)	High Risk (Any 1 Criterion in This Column)	Prohibitive Risk (Any 1 Criterion in This Column)
STS PROM^a	<4% AND	4%-8% OR	>8% OR	Predicted risk with surgery of death or major morbidity (all-cause) OR
Frailty^b	None AND	1 index (mild) OR	≥2 indices (moderate to severe) OR	>50% at 1 y OR
Major organ system compromise not to be improved postoperatively^c	None AND	1 organ system OR	No more than 2 organ systems OR	≥3 organ systems OR
Procedure-specific impediment^d	None	Possible procedure-specific impediment	Possible procedure-specific impediment	Severe procedure-specific impediment
^a Use of the STS PROM to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of STS average observed/expected ratio for the procedure in question. ^b Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) and independence in ambulation (no walking aid or assist required or 5-meter walk in <6 s). Other scoring systems can be applied to calculate no, mild-, or moderate-to-severe frailty. ^c Examples of major organ system compromise: Cardiac—severe LV systolic or diastolic dysfunction or RV dysfunction, fixed PHTN; CKD stage 3 or worse; pulmonary dysfunction with FEV1 <50% or DLCO2 <50% of predicted; CNS dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, stroke with persistent physical limitation); GI dysfunction—Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0; cancer—active malignancy; and liver—any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy. ^d Examples: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, or radiation damage.

Table 4. Initial Diagnostic Testing

Recommendations	COR	LOE
TTE is recommended in the initial evaluation of patients with known or suspected VHD to confirm the diagnosis, establish etiology, determine severity, assess hemodynamic consequences, determine prognosis, and evaluate for timing of intervention.	I	B
TTE is recommended in patients with known VHD with any change in symptoms or physical examination findings.	I	C
Periodic monitoring with TTE is recommended in asymptomatic patients with known VHD at intervals depending on valve lesion, severity, ventricular size, and ventricular function.	I	C
Cardiac catheterization for hemodynamic assessment is recommended in symptomatic patients when noninvasive tests are inconclusive or when there is a discrepancy between the findings on noninvasive testing and physical examination regarding severity of the valve lesion.	I	C
Exercise testing is reasonable in selected patients with asymptomatic severe VHD to confirm the absence of symptoms, or assess the hemodynamic response to exercise, or determine prognosis.	IIa	B

Table 5. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal LV Function

	Valve Lesion
Stage	AS^a	AR	MS	MR
Progressive (stage B)	Every 3-5 y (mild severity: Vmax 2.0-2.9 m/s) Every 1-2 y (moderate severity: Vmax 3.0-3.9 m/s)	Every 3-5 y (mild severity) Every 1-2 y (moderate severity)	Every 3-5 y (MVA >1.5 cm2)	Every 3-5 y (mild severity) Every 1-2 y (moderate severity)
Severe (stage C)	Every 6-12 mo (Vmax ≥4 m/s)	Every 6-12 mo Dilating LV: more frequently	Every 1-2 y (MVA 1.0-1.5 cm2) Once every year (MVA <1.0 cm²)	Every 6-12 mo Dilating LV: more frequently
Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single valve lesions. ^a With normal stroke volume.

Rheumatic Fever

Table 6. Secondary Prevention of Rheumatic Fever

Recommendations	COR	LOE
Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically MS (Tables 7-8).	I	C

Table 7. Agents for Secondary Prevention of Rheumatic Fever

Agent	Dosage
Penicillin G benzathine	1.2 million units IM every 4 wk^a
Penicillin V potassium	250 mg orally BID
Sulfadiazine	1 g orally QD
Macrolide or azalide antibiotic (for patients allergic to penicillin and sulfadiazine)^b	Varies
^a Administration every 3 wk is recommended in certain high-risk situations. ^b Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors. Adapted with permission from Gerber et al. Circulation. 2009;119:1541-1551.

Table 8. Duration of Secondary Prophylaxis for Rheumatic Fever

Type	Duration After Last Attack
Rheumatic fever with carditis and residual heart disease (persistent VHD^a)	10 y or until patient is 40 y of age (whichever is longer)
Rheumatic fever with carditis but no residual heart disease (no valvular disease^a)	10 y or until patient is 21 y of age (whichever is longer)
Rheumatic fever without carditis	5 y or until patient is 21 y of age (whichever is longer)
^a Clinical or echocardiographic evidence. Adapted with permission from Gerber et al. Circulation. 2009;119:1541-1551.

Aortic Stenosis

Table 9. Stages of Valvular AS

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
A	At risk of AS	Bicuspid aortic valve (or other congenital valve anomaly) Aortic valve sclerosis	Aortic Vmax <2 m/s	None	None
B	Progressive AS	Mild-to-moderate leaflet calcification of a bicuspid or trileaflet valve with some reduction in systolic motion or Rheumatic valve changes with commissural fusion	Mild AS: Aortic Vmax 2.0-2.9 m/s or ∆Pmean <20 mm Hg Moderate AS: Aortic Vmax 3.0-3.9 m/s or ∆Pmean 20-39 mm Hg	Early LV diastolic dysfunction may be present Normal LVEF	None
C: Asymptomatic severe AS
C1	Asymptomatic severe AS	Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening	Aortic Vmax ≥4 m/s or ∆Pmean ≥40 mm Hg AVA typically ≤1.0 cm2 (or AVAi ≤0.6 cm2/m2) Very severe AS: Aortic Vmax ≥5 m/s or ∆Pmean ≥60 mm Hg	LV diastolic dysfunction Mild LV hypertrophy Normal LVEF	None: Exercise testing is reasonable to confirm symptom status
C2	Asymptomatic severe AS with LV dysfunction	Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening	Aortic Vmax ≥4 m/s or ∆Pmean ≥40 mm Hg AVA typically ≤1.0 cm2 (or AVAi ≤0.6 cm2/m2)	LVEF <50%	None
D: Symptomatic severe AS
D1	Symptomatic severe high- gradient AS	Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening	Aortic Vmax ≥4 m/s or ∆Pmean ≥40 mm Hg AVA typically ≤1.0 cm2 (or AVAi ≤0.6 cm2/m2) but may be larger with mixed AS/AR	LV diastolic dysfunction LV hypertrophy PHTN may be present	Exertional dyspnea or decreased exercise tolerance Exertional angina Exertional syncope or presyncope
D2	Symptomatic severe low-flow/low-gradient AS with reduced LVEF	Severe leaflet calcification with severely reduced leaflet motion	AVA ≤1.0 cm2 with resting aortic Vmax <4 m/s or ∆Pmean <40 mm Hg DSE shows AVA ≤1.0 cm2 with Vmax ≥4 m/s at any flow rate	LV diastolic dysfunction LV hypertrophy LVEF <50%	HF Angina Syncope or presyncope
D3	Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS	Severe leaflet calcification with severely reduced leaflet motion	AVA ≤1.0 cm2 with aortic Vmax <4 m/s or ∆Pmean <40 mm Hg Indexed AVA ≤0.6 cm2/m2 and Stroke volume index <35 mL/m2 Measured when patient is normotensive (systolic BP <140 mm Hg)	Increased LV relative wall thickness Small LV chamber with low stroke volume Restrictive diastolic filling LVEF ≥50%	HF Angina Syncope or presyncope

Table 10. Evaluation and Treatment in Patients With AS

Recommendations	COR	LOE
Diagnostic Testing
TTE is indicated in patients with signs or symptoms of AS or a bicuspid aortic valve for accurate diagnosis of the cause of AS, hemodynamic severity, LV size and systolic function, and for determining prognosis and timing of valve intervention.	I	B
Low-dose dobutamine stress testing using echocardiographic or invasive hemodynamic measurements is reasonable in patients with stage D2 AS with all of the following: Calcified aortic valve with reduced systolic opening; LVEF <50%; Calculated valve area ≤1.0 cm2; and Aortic velocity <4.0 m/s or ∆Pmean <40 mm Hg.	I	B
Exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms in asymptomatic patients with a calcified aortic valve and aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg (stage C).	IIa	B
Exercise testing should *NOT* be performed in symptomatic patients with AS when the aortic velocity is ≥4.0 m/s or ∆Pmean is ≥40 mm Hg (stage D).	III: Harm	B
Medical Therapy
Hypertension in patients at risk for developing AS (stage A) and in patients with asymptomatic AS (stages B and C) should be treated according to standard GDMT, started at a low dose and gradually titrated upward as needed with frequent clinical monitoring.	I	B
Vasodilator therapy may be reasonable if used with invasive hemodynamic monitoring in the acute management of patients with severe decompensated AS (stage D) with NYHA class IV HF symptoms.	IIb	C
Statin therapy is *NOT* indicated for prevention of hemodynamic progression of AS in patients with mild-to-moderate calcific valve disease (stages B-D).	III: No Benefit	A

Table 11. Indications for AVR in Patients With AS

Recommendations	COR	LOE
AVR is recommended in symptomatic patients with severe AS (stage D1) with: Decreased systolic opening of a calcified or congenitally stenotic aortic valve; and Aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg; and Symptoms of HF, syncope, exertional dyspnea, angina, or presyncope by history or on exercise testing.	I	B
AVR is recommended for asymptomatic patients with severe AS (stage C2) and LVEF <50% with decreased systolic opening of a calcified aortic valve with an aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg.	I	B
AVR is indicated for patients with very severe AS (stage C or D) when undergoing cardiac surgery for other indications when there is decreased systolic opening of a calcified aortic valve and aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg.	I	B
AVR is reasonable for asymptomatic patients with severe AS (stage C1) with: Decreased systolic opening of a calcified valve; Aortic velocity ≥5.0 m/s or ∆Pmean ≥60 mm Hg; Low surgical risk.	IIa	B
AVR is reasonable in apparently asymptomatic patients with severe AS (stage C1) with: A calcified aortic valve; Aortic velocity 4.0-4.9 m/s or ∆Pmean of 40-59 mm Hg; An exercise test demonstrating decreased exercise tolerance or a fall in systolic BP.	IIa	B
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a: Calcified aortic valve with reduced systolic opening; Resting valve area ≤1.0 cm2; Aortic velocity <4 m/s or ∆Pmean<40 mm Hg; LVEF <50%; and Low-dose dobutamine stress study that shows aortic velocity ≥4 m/s or ∆Pmean ≥40 mm Hg with valve area ≤1.0 cm2 at any dobutamine dose.	IIa	B
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS (stage D3) with LVEF ≥50%, a calcified aortic valve with significantly reduced leaflet motion, and a valve area ≤1.0 cm2 only if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms and data recorded when the patient is normotensive (systolic BP <140 mm Hg) indicate: An aortic velocity <4 m/s or ∆Pmean <40 mm Hg; A stroke volume index <35 mL/m2; and An indexed valve area ≤0.6 cm2/m2.	IIa	C
AVR is reasonable for patients with moderate AS (stage B) with an aortic velocity 3.0-3.9 m/s or ∆Pmean 20-39 mm Hg who are undergoing cardiac surgery for other indications.	IIa	C
AVR may be considered for asymptomatic patients with severe AS (stage C1) with aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg if the patient is at low surgical risk and serial testing shows an increase in aortic velocity ≥0.3 m/s/y.	IIb	C

Table 12. Choice of Intervention in Patients With AS

Recommendations	COR	LOE
Surgical AVR is recommended in patients who meet an indication for AVR with low or intermediate surgical risk.	I	A
For patients in whom TAVR or high-risk surgical AVR is being considered, a Heart Valve Team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care.	I	C
TAVR is recommended in patients who meet an indication for AVR who have a prohibitive risk for surgical AVR and a predicted post-TAVR survival >12 months.	I	B
TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk for surgical AVR.	IIa	B
Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR in patients with severe symptomatic AS.	IIb	C
TAVR is *NOT* recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS.	III: No Benefit	B

Figure 1. Indications for AVR in Patients With AS

Table 13. Stages of Chronic AR

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
A	At risk of AR	Bicuspid aortic valve (or other congenital valve anomaly) Aortic valve sclerosis Diseases of the aortic sinuses or ascending aorta History of rheumatic fever or known rheumatic heart disease IE	AR severity: none or trace	None	None
B	Progressive AR	Mild-to-moderate calcification of a trileaflet valve, bicuspid aortic valve (or other congenital valve anomaly) Dilated aortic sinuses Rheumatic valve changes Previous IE	Mild AR: Jet width <25% of LVOT; Vena contracta <0.3 cm; RVol <30 mL/beat; RF <30%; ERO <0.10 cm2; Angiography grade 1+ Moderate AR: Jet width 25%-64% of LVOT; Vena contracta 0.3-0.6 cm; RVol 30-59 mL/beat; RF 30%-49%; ERO 0.10-0.29 cm2; Angiography grade 2+	Normal LV systolic function Normal LV volume or mild LV dilation	None
C	Asymptomatic severe AR	Calcific aortic valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes IE with abnormal leaflet closure or perforation	Severe AR: Jet width ≥65% of LVOT; Vena contracta >0.6 cm; Holodiastolic flow reversal in the proximal abdominal aorta; RVol ≥60 mL/beat; RF ≥50%; ERO ≥0.3 cm2; Angiography grade 3+-4+; In addition, diagnosis of chronic severe AR requires evidence of LV dilation	C1: Normal LVEF (≥50%) and mild-to-moderate LV dilation (LVESD ≤50 mm) C2: Abnormal LV systolic function with depressed LVEF (<50%) or severe LV dilatation (LVESD >50 mm or indexed LVESD >25 mm/m2)	None; exercise testing is reasonable to confirm symptom status
D	Symptomatic severe AR	Calcific valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes Previous IE with abnormal leaflet closure or perforation	Severe AR: Doppler jet width ≥65% of LVOT; Vena contracta >0.6 cm; Holodiastolic flow reversal in the proximal abdominal aorta; RVol ≥60 mL/beat; RF ≥50%; ERO ≥0.3 cm2; Angiography grade 3+-4+; In addition, diagnosis of chronic severe AR requires evidence of LV dilation	Symptomatic severe AR may occur with normal systolic function (LVEF ≥50%), mild-to-moderate LV dysfunction (LVEF 40%-50%), or severe LV dysfunction (LVEF <40%) Moderate-to-severe LV dilation	Exertional dyspnea or angina or more severe HF symptoms

Table 14. Diagnosis, Medical Therapy, and Intervention in Patients With Chronic AR

Recommendations	COR	LOE
TTE is indicated in patients with signs or symptoms of AR (stages A-D) for accurate diagnosis of the cause of regurgitation, regurgitant severity, and LV size and systolic function, and for determining clinical outcome and timing of valve intervention.	I	B
TTE is indicated in patients with dilated aortic sinuses or ascending aorta or with a bicuspid aortic valve (stages A and B) to evaluate the presence and severity of AR.	I	B
CMR is indicated in patients with moderate or severe AR (stages B-D) and suboptimal echocardiographic images for the assessment of LV systolic function, systolic and diastolic volumes, and measurement of AR severity.	I	B
Medical Therapy
Treatment of hypertension (systolic BP >140 mm Hg) is recommended in patients with chronic AR (stages B and C), preferably with dihydropyridine calcium channel blockers or ACE inhibitors/ARBs.	I	B
Medical therapy with ACE inhibitors/ARBs and beta blockers is reasonable in patients with severe AR who have symptoms and/or LV dysfunction (stages C2 and D) when surgery is not performed because of comorbidities.	IIa	B
Surgical Intervention
AVR is indicated for symptomatic patients with severe AR regardless of LV systolic function (stage D).	I	B
AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF <50%) at rest (stage C2) if no other cause for systolic dysfunction is identified.	I	B
AVR is indicated for patients with severe AR (stage C or D) while undergoing cardiac surgery for other indications.	I	C
AVR is reasonable for asymptomatic patients with severe AR with normal LV systolic function (LVEF ≥50%) but with severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m2) (stage C2).	IIa	B
AVR is reasonable in patients with moderate AR (stage B) while undergoing surgery on the ascending aorta, CABG, or MV surgery.	IIa	C
AVR may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF ≥50%, stage C1) but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low.	IIb	C

Figure 2. Indications for AVR for Chronic AR

Bicuspid Aortic Valve and Aortopathy

Table 15. Diagnosis and Intervention in Patients With Bicuspid Aortic Valve and Aortopathy

Recommendations	COR	LOE
Diagnosis
An initial TTE is indicated in patients with a known bicuspid aortic valve to evaluate valve morphology, to measure the severity of AS and AR, and to assess the shape and diameter of the aortic sinuses and ascending aorta for prediction of clinical outcome and to determine timing of intervention.	I	B
Aortic magnetic resonance angiography or CT angiography is indicated in patients with a bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography.	I	C
Serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is recommended in patients with a bicuspid aortic valve and an aortic diameter >4.0 cm, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history. In patients with an aortic diameter >4.5 cm, this evaluation should be performed annually.	I	C
Surgical Intervention
Operative intervention to repair the aortic sinuses or replace the ascending aorta is indicated in patients with a bicuspid aortic valve if the diameter of the aortic sinuses or ascending aorta is >5.5 cm	I	B
Operative intervention to repair the aortic sinuses or replace the ascending aorta is reasonable in patients with bicuspid aortic valves if the diameter of the aortic sinuses or ascending aorta is >5.0 cm and a risk factor for dissection is present (family history of aortic dissection or if the rate of increase in diameter ≥0.5 cm per year).	IIa	C
Replacement of the ascending aorta is reasonable in patients with a bicuspid aortic valve who are undergoing aortic valve surgery because of severe AS or AR if the diameter of the ascending aorta is >4.5 cm.	IIa	C

Mitral Stenosis

Figure 3. Indications for Intervention in Patients With Rheumatic MS

Table 16. Stages of MS

Stage	Definition	Valve Anatomy	Valve Hemodynamics^a	Hemodynamic Consequences	Symptoms
A	At risk of MS	Mild valve doming during diastole	Normal transmitral flow velocity	None	None
B	Progressive MS	Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets Planimetered MVA >1.5 cm²	Increased transmitral flow velocities MVA >1.5 cm2 Diastolic pressure half-time <150 ms	Mild-to-moderate LA enlargement Normal pulmonary pressure at rest	None
C	Asymptomatic severe MS	Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets Planimetered MVA ≤1.5 cm² (MVA ≤1.0 cm2 with very severe MS)	MVA ≤1.5 cm² (MVA ≤1.0 cm2 with severe MS) Diastolic pressure half-time ≥150 ms (Diastolic pressure half-time ≥220 ms with severe MS)	Severe LA enlargement Elevated PASP >30 mm Hg	None
D	Symptomatic severe MS	Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets Planimetered MVA ≤1.5 cm²	MVA ≤1.5 cm2 (MVA ≤1.0 cm2 with very severe MS) Diastolic pressure half-time ≥150 ms (Diastolic pressure half-time ≥220 ms with very severe MS)	Severe LA enlargement Elevated PASP >30 mm Hg	Decreased exercise tolerance Exertional dyspnea
^a The transmitral ΔP mean should be obtained to further determine the hemodynamic effect of the MS and is usually >5-10 mm Hg in severe MS. However, due to the variability of the ΔPmean with heart rate and forward flow, it has not been included in the criteria for severity.

Table 17A. Diagnosis and Medical Therapy in Patients With MS

Recommendations	COR	LOE
TTE is indicated in patients with signs or symptoms of MS to establish the diagnosis, quantify hemodynamic severity (ΔP_mean, MVA, and PA pressure), assess concomitant valvular lesions, and demonstrate valve morphology (to determine suitability for mitral commissurotomy).	I	B
TEE should be performed in patients considered for PMBC to assess the presence or absence of left atrial thrombus and to further evaluate the severity of MR.	I	B
Exercise testing with Doppler or invasive hemodynamic assessment is recommended to evaluate the response of the mean mitral gradient and PA pressure in patients with MS when there is a discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs.	I	C
Anticoagulation (VKA or heparin) is indicated in patients with MS and AF (paroxysmal, persistent, or permanent), or MS and a prior embolic event, or MS and a left atrial thrombus.	I	B
Heart rate control can be beneficial in patients with MS and AF and fast ventricular response.	IIa	C
Heart rate control may be considered for patients with MS in normal sinus rhythm and symptoms associated with exercise.	IIb	B

Table 17B. Intervention in Patients With MS

Recommendations	COR	LOE
PMBC is recommended for symptomatic patients with severe MS (MVA ≤1.5 cm2, stage D) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe MR.	I	A
MV surgery (repair, commissurotomy, or valve replacement) is indicated in severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D) who are not high risk for surgery and who are not candidates for or who have failed previous PMBC.	I	B
Concomitant MV surgery is indicated for patients with severe MS (MVA ≤1.5 cm2, stage C or D) undergoing cardiac surgery for other indications.	I	C
PMBC is reasonable for asymptomatic patients with very severe MS (MVA ≤1.0 cm2, stage C) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe MR.	IIa	C
MV surgery is reasonable for severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D), provided there are other operative indications (eg, aortic valve disease, CAD, TR, aortic aneurysm).	IIa	C
PMBC may be considered for asymptomatic patients with severe MS (MVA ≤1.5 cm2, stage C) and valve morphology favorable for PMBC in the absence of left atrial thrombus or moderate-to-severe MR who have new onset of AF.	IIb	C
PMBC may be considered for symptomatic patients with MVA >1.5 cm2 if there is evidence of hemodynamically significant MS based on PAWP >25 mm Hg or mean MV gradient >15 mm Hg during exercise.	IIb	C
PMBC may be considered for severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D) who have suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery.	IIb	C
Concomitant MV surgery may be considered for patients with moderate MS (MVA 1.6-2.0 cm2) undergoing cardiac surgery for other indications.	IIb	C
MV surgery and excision of the left atrial appendage may be considered for patients with severe MS (MVA ≤1.5 cm2, stages C and D) who have had recurrent embolic events while receiving adequate anticoagulation.	IIb	C

Table 18A. Stages of Primary MR

Stage	Definition	Valve Anatomy	Valve Hemodynamics^a	Hemodynamic Consequences	Symptoms
A	At risk of MR	Mild MV prolapse with normal coaptation Mild valve thickening and leaflet restriction	No MR jet or small central jet area <20% LA on Doppler Small vena contracta <0.3 cm	None	None
B	Progressive MR	Severe MV prolapse with normal coaptation Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE	Central jet MR 20%-40% LA or late systolic eccentric jet MR Vena contracta <0.7 cm RVol <60 mL RF <50% ERO <0.40 cm² Angiographic grade 1+-2+	Mild LA enlargement No LV enlargement Normal pulmonary pressure	None
C	Asymptomatic severe MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm RVol ≥60 mL RF ≥50% ERO ≥0.40 cm2 Angiographic grade 3+-4+	Moderate or severe LA enlargement LV enlargement PHTN may be present at rest or with exercise C1: LVEF >60% and LVESD <40 mm C2: LVEF ≤60% and LVESD ≥40 mm	None
D	Symptomatic severe MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm RVol ≥60 mL RF ≥50% ERO ≥0.40 cm2 Angiographic grade 3+-4+	Moderate or severe LA enlargement LV enlargement PHTN present	Decreased exercise tolerance Exertional dyspnea
^a Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence.

Table 18B. Stages of Secondary MR

Stage	Definition	Valve Anatomy	Valve Hemodynamics^a	Associated Cardiac Findings	Symptoms
A	At risk of MR	Normal valve leaflets, chords, and annulus in a patient with coronary disease or cardiomyopathy	No MR jet or small central jet area <20% LA on Doppler Small vena contracta <0.30 cm	Normal or mildly dilated LV with fixed (infarction) or inducible (ischemia) regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
B	Progressive MR	Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets	ERO <0.20 cm² b RVol <30 mL RF <50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
C	Asymptomatic severe MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	ERO ≥0.20 cm² b RVol ≥30 mL RF ≥50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
D	Symptomatic severe MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of mitral leaflets	ERO ≥0.20 cm² b RVol ≥30 mL RF ≥50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	HF symptoms due to MR persist even after revascularization and optimization of medical therapy Decreased exercise tolerance Exertional dyspnea
^a Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence. ^b The measurement of the proximal isovelocity surface area by 2D TTE in patients with chronic secondary MR underestimates the true ERO due to the crescent shape of the proximal convergence.

Table 19. Diagnosis and Medical Therapy in Patients With Chronic Primary MR

Recommendations	COR	LOE
Diagnosis
TTE is indicated for baseline evaluation of LV size and function, RV function and LA size, PA pressure, and mechanism and severity of primary MR (stages A-D) in any patient suspected of having chronic primary MR.	I	B
CMR is indicated in patients with chronic primary MR to assess LV and RV volumes, function, or MR severity and when these issues are not satisfactorily addressed by TTE.	I	B
Intraoperative TEE is indicated to establish the anatomic basis for chronic primary MR (stages C and D) and to guide repair.	I	B
TEE is indicated for evaluation of patients with chronic primary MR (stages B-D) in whom noninvasive imaging provides nondiagnostic information about severity of MR, mechanism of MR, and/or status of LV function.	I	C
Exercise hemodynamics with either Doppler echocardiography or cardiac catheterization is reasonable in symptomatic patients with chronic primary MR where there is a discrepancy between symptoms and severity of MR at rest (stages B and C).	IIa	B
Exercise treadmill testing can be useful in patients with chronic primary MR to establish symptom status and exercise tolerance (stages B and C).	IIa	C
Medical Therapy
Medical therapy for systolic dysfunction is reasonable in symptomatic patients with chronic primary MR (stage D) and LVEF <60% in whom surgery is not contemplated.	IIa	B
Vasodilator therapy is *NOT* indicated for normotensive asymptomatic patients with chronic primary MR (stages B and C1) and normal systolic LV function.	III: No Benefit	B

Table 20. Intervention in Patients With Chronic Primary MR

Recommendations	COR	LOE
MV surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF >30%.	I	B
MV surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30%-60% and/or LVESD ≥40 mm, stage C2).	I	B
MV repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet.	I	B
MV repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished.	I	B
Concomitant MV repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications.	I	B
MV repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <40 mm) in whom the likelihood of a successful and durable repair without residual MR is >95% with an expected mortality rate of <1% when performed at a Heart Valve Center of Excellence.	IIa	B
MV repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting PHTN (PA systolic arterial pressure >50 mm Hg).	IIa	B
Concomitant MV repair is reasonable in patients with chronic moderate primary MR (stage B) undergoing cardiac surgery for other indications.	IIa	C
MV surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF ≤30% (stage D).	IIb	C
MV repair may be considered in patients with rheumatic MV disease when surgical treatment is indicated if a durable and successful repair is likely or if the reliability of long-term anticoagulation management is questionable.	IIb	B
Transcatheter MV repair may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for HF.	IIb	B
MVR should *NOT* be performed for treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessful.	III: Harm	B

Table 21. Diagnosis and Treatment of Patients With Chronic Secondary MR

Recommendations	COR	LOE
Diagnosis
TTE is useful to establish the etiology of chronic secondary MR (stages B-D) and the extent and location of wall motion abnormalities and to assess global LV function, severity of MR, and magnitude of PHTN.	I	C
Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B-D) and/or to assess myocardial viability, which in turn may influence management of functional MR.	I	C
Medical Therapy
Patients with chronic secondary MR (stages B-D) and HF with reduced LVEF should receive standard GDMT therapy for HF, including ACE inhibitors, ARBs, beta blockers, and/or aldosterone antagonists as indicated.	I	A
CRT with biventricular pacing is recommended for symptomatic patients with chronic severe secondary MR (stages B-D) who meet the indications for device therapy.	I	A
Surgical Intervention
MV surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR.	IIa	C
MV repair or replacement may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT for HF.	IIb	B
MV repair may be considered for patients with chronic moderate secondary MR (stage B) who are undergoing other cardiac surgery.	IIb	C

Figure 4. Indications for Surgery for MR

TV Disease

Table 22. Stages of TR

Stage	Definition	Valve Anatomy	Valve Hemodynamics^a	Hemodynamic Consequences	Symptoms
A	At risk of TR	Primary: Mild rheumatic change Mild prolapse Other (eg, IE with vegetation, early carcinoid deposition, radiation) Intra-annular RV pacemaker or ICD lead Postcardiac transplant (biopsy related) Functional: Normal Early annular dilation	No or trace TR	None	None or in relation to other left heart or pulmonary/pulmonary vascular disease
B	Progressive TR	Primary: Progressive leaflet deterioration/destruction Moderate-to-severe prolapse, limited chordal rupture Functional: Early annular dilation Moderate leaflet tethering	Mild TR: Central jet area <5.0 cm² Vena contracta width not defined CW jet density and contour: soft and parabolic Hepatic vein flow: systolic dominance Moderate TR: Central jet area 5-10 cm² Vena contracta width not defined but <0.70 cm CW jet density and contour: dense, variable contour Hepatic vein flow: systolic blunting	Mild TR: RV/RA/IVC size normal Moderate TR: No RV enlargement No or mild RA enlargement No or mild IVC enlargement with normal respirophasic variation Normal RA pressure	None or in relation to other left heart or pulmonary/pulmonary vascular disease
C	Asymptomatic severe TR	Primary: Flail or grossly distorted leaflets Functional: Severe annular dilation (>40 mm or 21 mm/m2) Marked leaflet tethering	Central jet area >10.0 cm² Vena contracta width >0.7 cm CW jet density and contour: dense, triangular with early peak Hepatic vein flow: systolic reversal	RV/RA/IVC dilated with decreased IVC respirophasic variation Elevated RA pressure with “c-V” wave Diastolic interventricular septal flattening may be present	None, or in relation to other left heart or pulmonary/pulmonary vascular disease
D	Symptomatic severe TR	Primary: Flail or grossly distorted leaflets Functional: Severe annular dilation (>40 mm or >21 mm/m2) Marked leaflet tethering	Central jet area >10.0 cm² Vena contracta width >0.70 cm CW jet density and contour: dense, triangular with early peak Hepatic vein flow: systolic reversal	RV/RA/IVC dilated with decreased IVC respirophasic variation Elevated RA pressure with “c-V” wave Diastolic interventricular septal flattening Reduced RV systolic function in late phase	Fatigue, palpitations, dyspnea, abdominal bloating, anorexia, edema
^a Several valve hemodynamic criteria are provided for assessment of severity of TR, but not all criteria for each category will necessarily be present in every patient. Categorization of severity of TR as mild, moderate, or severe also depends on image quality and integration of these parameters with clinical findings.

Table 23. Diagnosis, Medical Therapy, and Surgery in Patients With TR

Recommendations	COR	LOE
Diagnosis
TTE is indicated to evaluate severity of TR, determine etiology, measure size of right-sided chambers and IVC, assess RV systolic function, estimate PASP, and characterize any associated left-sided heart disease.	I	C
Invasive measurement of PA pressures and pulmonary vascular resistance can be useful in patients with TR when clinical and noninvasive data regarding their values are discordant.	IIa	C
CMR or real-time 3D echocardiography may be considered for assessment of RV systolic function and systolic and diastolic volume in patients with severe TR (stages C and D) and suboptimal 2D echocardiograms.	IIb	C
Exercise testing may be considered for the assessment of exercise capacity in patients with severe TR with no or minimal symptoms (stage C).	IIb	C
Medical Therapy
Diuretics can be useful for patients with severe TR and signs of right-sided HF (stage D).	IIa	C
Medical therapies to reduce elevated PA pressures and/or pulmonary vascular resistance might be considered in patients with severe functional TR (stages C and D).	IIb	C
Surgery
TV surgery is recommended for patients with severe TR (stages C and D) undergoing left-sided valve surgery.	I	C
TV repair can be beneficial for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either 1) TA dilation or 2) prior evidence of right HF.	IIa	B
TV surgery can be beneficial for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D).	IIa	C
TV repair may be considered for patients with moderate functional TR (stage B) and PHTN at the time of left-sided valve surgery.	IIb	C
TV surgery may be considered for asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction.	IIb	C
Reoperation for isolated TV repair or replacement may be considered for persistent symptoms due to severe TR (stage D) in patients who have undergone previous left-sided valve surgery and who do not have severe PHTN or significant RV systolic dysfunction.	IIb	C

Figure 5. Indications for Surgery in Patients With TR

Tricuspid Stenosis

Table 24. Stages of Severe TS

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
C, D	Severe TS	Thickened, distorted, calcified leaflets	T½ ≥190 ms Valve area ≤1.0 cm²	RA/IVC enlargement	None or variable and dependent on severity of associated valve disease and degree of obstruction
The transtricuspid diastolic gradient is highly variable and is affected by heart rate, forward flow, and phases of the respiratory cycle. However, severe TS usually has ∆P_means >5-10 mm Hg at heart rate 70.

Table 25. Diagnosis and Intervention in Patients With TS

Recommendations	COR	LOE
Diagnosis
TTE is indicated in patients with TS to assess the anatomy of the valve complex, evaluate severity of stenosis, and characterize any associated regurgitation and/or left-sided valve disease.	I	C
Invasive hemodynamic assessment of severity of TS may be considered in symptomatic patients when clinical and noninvasive data are discordant.	IIb	C
Intervention
TV surgery is recommended for patients with severe TS at the time of operation for left-sided valve disease.	I	C
TV surgery is recommended for patients with isolated, symptomatic severe TS.	I	C
Percutaneous balloon tricuspid commissurotomy might be considered in patients with isolated, symptomatic severe TS without accompanying TR.	IIb	C

Pulmonic Valve Disease

Table 26. Stages of Severe PR

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
C, D	Severe PR	Distorted or absent leaflets, annular dilation	Color jet fills RVOT CW jet density and contour: dense laminar flow with steep deceleration slope; may terminate abruptly	Paradoxical septal motion (volume overload pattern) RV enlargement	None or variable and dependent on cause of PR and RV function

Table 27. Stages of Severe PS

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
C, D	Severe PS	Thickened, distorted, possibly calcified leaflets with systolic doming and/or reduced excursion Other anatomic abnormalities may be present, such as narrowed RVOT	V_max >4 m/s; peak instantaneous gradient >64 mm Hg	RVH Possible RV, RA enlargement Poststenotic enlargement of main PA	None or variable and dependent on severity of obstruction

Prosthetic Valves

Table 28. Diagnosis and Anticoagulation for Prosthetic Valves

Recommendations	COR	LOE
Diagnosis
An initial TTE study is recommended in patients after prosthetic valve implantation for evaluation of valve hemodynamics.	I	B
Repeat TTE is recommended in patients with prosthetic heart valves if there is a change in clinical symptoms or signs suggesting valve dysfunction.	I	C
TEE is recommended when clinical symptoms or signs suggest prosthetic valve dysfunction.	I	C
Annual TTE is reasonable in patients with a bioprosthetic valve after the first 10 years, even in the absence of a change in clinical status.	IIa	C
Antithrombotic Therapy
Anticoagulation with a VKA and INR monitoring is recommended in patients with a mechanical prosthetic valve.	I	A
Anticoagulation with a VKA to achieve an INR of 2.5 is recommended in patients with a mechanical AVR (bileaflet or current-generation single tilting disc) and no risk factors for thromboembolism.	I	B
Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical AVR and additional risk factors for thromboembolic events (AF, previous thromboembolism, LV dysfunction, or hypercoagulable conditions) or an older-generation mechanical AVR (such as ball-in-cage).	I	B
Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical MVR.	I	B
ASA 75-100 mg daily is recommended in addition to anticoagulation with a VKA in patients with a mechanical valve prosthesis.	I	A
ASA 75-100 mg daily is reasonable in all patients with a bioprosthetic aortic or MV.	IIa	B
Anticoagulation with a VKA is reasonable for the first 3 months after bioprosthetic MVR or repair to achieve an INR of 2.5.	IIa	C
Anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for the first 3 months after bioprosthetic AVR.	IIb	B
Clopidogrel 75 mg daily may be reasonable for the first 6 months after TAVR in addition to lifelong ASA 75-100 mg daily.	IIb	C
Anticoagulant therapy with oral direct thrombin inhibitors or anti-Xa agents should *NOT* be used in patients with mechanical valve prostheses.	III: Harm	B
Bridging Therapy
Continuation of VKA anticoagulation with a therapeutic INR is recommended in patients with mechanical heart valves undergoing minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled.	I	C
Temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended in patients with a bileaflet mechanical AVR and no other risk factors for thrombosis who are undergoing invasive or surgical procedures.	I	C
Bridging anticoagulation with either IV UFH or SC LMWH is recommended during the time interval when the INR is subtherapeutic preoperatively in patients who are undergoing invasive or surgical procedures with a 1) mechanical AVR and any thromboembolic risk factor, 2) older-generation mechanical AVR, or 3) mechanical MVR.	I	C
Administration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves receiving VKA therapy who require emergency noncardiac surgery or invasive procedures.	IIa	C
Administration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves and uncontrollable bleeding who require reversal of anticoagulation.	IIa	B

Table 29. Prosthetic Valve Choice

Recommendations	COR	LOE
The choice of valve intervention, that is, repair or replacement, as well as type of prosthetic heart valve, should be a shared decision-making process that accounts for the patient’s values and preferences, with full disclosure of the indications for and risks of anticoagulant therapy and the potential need for and risk of reoperation.	I	C
A bioprosthesis is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired.	I	C
A mechanical prosthesis is reasonable for AVR or MVR in patients <60 y of age who do not have a contraindication to anticoagulation.	IIa	B
A bioprosthesis is reasonable in patients >70 y of age.	IIa	B
Either a bioprosthetic or mechanical valve is reasonable in patients between 60 and 70 y of age.	IIa	B
Replacement of the aortic valve by a pulmonary autograft (the Ross procedure), when performed by an experienced surgeon, may be considered in young patients when VKA anticoagulation is contraindicated or undesirable.	IIb	C

Figure 6. Anticoagulation for Prosthetic Valves

Figure 7. Evaluation and Management of Suspected Prosthetic Valve Thrombosis

Table 30. Prosthetic Valve Complications

Recommendations
Prosthetic Valve Thrombosis
TTE is indicated in patients with suspected prosthetic valve thrombosis to assess hemodynamic severity and follow resolution of valve dysfunction.	I	B
TEE is indicated in patients with suspected prosthetic valve thrombosis to assess thrombus size and valve motion.	I	B
Fluoroscopy or CT is reasonable in patients with suspected valve thrombosis to assess valve motion.	IIa	C
Fibrinolytic therapy is reasonable for patients with a thrombosed left-sided prosthetic heart valve, recent onset (<14 days) of NYHA class I-II symptoms, and a small thrombus (<0.8 cm2).	IIa	B
Fibrinolytic therapy is reasonable for thrombosed right-sided prosthetic heart valves.	IIa	B
Emergency surgery is recommended for patients with a thrombosed left-sided prosthetic heart valve with NYHA class III-IV symptoms.	I	B
Emergency surgery is reasonable for patients with a thrombosed left-sided prosthetic heart valve with a mobile or large thrombus (>0.8 cm2).	IIa	C
Prosthetic Valve Stenosis
Repeat valve replacement is indicated for severe symptomatic prosthetic valve stenosis.	I	C
Prosthetic Valve Regurgitation
Surgery is recommended for operable patients with mechanical heart valves with intractable hemolysis or HF due to severe prosthetic or paraprosthetic regurgitation.	I	B
Surgery is reasonable for operable patients with severe symptomatic or asymptomatic bioprosthetic regurgitation.	IIa	C
Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or NYHA class III/IV HF who are at high risk for surgery and have anatomic features suitable for catheter-based therapy when performed in centers with expertise in the procedure.	IIa	B

Infectious Endocarditis

Figure 8. Recommendations for Imaging Studies in NVE and PVE

Figure 9. Diagnosis and Treatment of IE

Table 31A. Prophylaxis of IE

Recommendations	COR	LOE
Prophylaxis
Prophylaxis against IE is reasonable for the following patients at highest risk for adverse outcomes from IE before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa: Patients with prosthetic cardiac valves; Patients with previous IE; Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve; or Patients with congenital heart disease: Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits; Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure; Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.	IIa	B
Prophylaxis against IE is *NOT* recommended in patients with VHD who are at risk of IE for nondental procedures (eg, TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection.	III: No Benefit	B

Table 31B. Diagnosis and Treatment of IE

Recommendations	COR	LOE
Diagnosis
At least 2 sets of blood cultures should be obtained in patients at risk for IE (eg, those with congenital or acquired VHD, previous IE, prosthetic heart valves, certain congenital or heritable heart malformations, immunodeficiency states, or injection drug users) who have unexplained fever for more than 48 hours	I	B
or patients with newly diagnosed left-sided valve regurgitation.	I	C
The Modified Duke Criteria should be used in evaluating a patient with suspected IE (Tables 32-33).	I	B
Cardiac CT is reasonable to evaluate morphology/anatomy in the setting of suspected paravalvular infections when the anatomy cannot be clearly delineated by echocardiography.	IIa	B
TEE & TTE
TTE is recommended in patients with suspected IE to identify vegetations, characterize the hemodynamic severity of valvular lesions, assess ventricular function and pulmonary pressures, and detect complications.	I	B
TEE is recommended in all patients with known or suspected IE when TTE is nondiagnostic, when complications have developed or are clinically suspected, or when intracardiac device leads are present.	I	B
TTE and/or TEE are recommended for re-evaluation of patients with IE who have a change in clinical signs or symptoms (eg, new murmur, embolism, persistent fever, HF, abscess, or atrioventricular heart block) and in patients at high risk of complications (eg, extensive infected tissue/large vegetation on initial echocardiogram or staphylococcal, enterococcal, or fungal infections).	I	B
Intraoperative TEE is recommended for patients undergoing valve surgery for IE.	I	B
TEE is reasonable to diagnose possible IE in patients with S. aureus bacteremia without a known source.	IIa	B
TEE is reasonable to diagnose IE of a prosthetic valve in the presence of persistent fever without bacteremia or a new murmur.	IIa	B
TEE might be considered to detect concomitant staphylococcal IE in nosocomial S. aureus bacteremia with a known portal of entry from an extracardiac source.	IIb	B
Medical Therapy
Patients with IE should be evaluated and managed with consultation of a multispecialty Heart Valve Team including an infectious disease specialist, cardiologist, and cardiac surgeon. In surgically managed patients, this team should also include a cardiac anesthesiologist.	I	B
Appropriate antibiotic therapy should be initiated and continued after blood cultures are obtained, with guidance from antibiotic sensitivity data and infectious disease consultants.	I	B
It is reasonable to temporarily discontinue anticoagulation in patients with IE who develop CNS symptoms compatible with embolism or stroke, regardless of other indications for anticoagulation.	IIa	B
Temporary discontinuation of VKA anticoagulation might be considered in patients receiving VKA anticoagulation at the time of IE diagnosis.	IIb	B
Patients with known VHD should *NOT* receive antibiotics before blood cultures are obtained for unexplained fever.	III: Harm	C
Surgical Therapy
Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists.	I	B
Early surgerya is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF.	I	B
Early surgerya is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms.	I	B
Early surgerya is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions.	I	B
Early surgerya for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5-7 days after onset of appropriate antimicrobial therapy.	I	B
Surgery is recommended for patients with PVE and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection.	I	C
Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads.	I	B
Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection.	IIa	B
Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE.	IIa	C
Early surgerya is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy.	IIa	B
Early surgerya may be considered in patients with NVE who exhibit mobile vegetations >10 mm in length (with or without clinical evidence of embolic phenomena).	IIb	B
a Early surgery is defined as during initial hospitalization before completion of a full therapeutic course of antibiotics.

Table 32. Diagnosis of IE According to Proposed Modified Duke Criteria

Definite IE	Pathologic criteria Microorganisms demonstrated by culture or histologic examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen; or Pathologic lesions: vegetation or intracardiac abscess confirmed by histologic examination showing active endocarditis
	Clinical criteria 2 major criteria; or 1 major criterion and 3 minor criteria; or 5 minor criteria
Possible IE	1 major criterion and 1 minor criterion or 3 minor criteria
	Rejected Firm alternative diagnosis explaining evidence of IE; or Resolution of IE syndrome with antibiotic therapy for <4 d; or No pathologic evidence of IE at surgery or autopsy, with antibiotic therapy for <4 d; or Does not meet criteria for possible IE as listed above

Table 33. Modified Duke Criteria for Diagnosis of IE

Major Criteria	1. Blood culture positive for IE Typical microorganisms consistent with IE from 2 separate blood cultures: Viridans streptococci, Streptococcus bovis, HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae), S. aureus; or community-acquired enterococci, in the absence of a primary focus; or Microorganisms consistent with IE from persistently positive blood cultures, defined as follows: At least 2 positive cultures of blood samples drawn 12 h apart or All of 3 or a majority of ≥4 separate positive blood cultures (with first and last samples drawn at least 1 h apart) or Single positive blood culture for Coxiella burnetii or antiphase I IgG antibody titer >1:800
	2. Evidence of endocardial involvement Echocardiogram positive for IE defined as follows: Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; Abscess; or New partial dehiscence of prosthetic valve New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient)
Minor Criteria	1. Predisposition, predisposing heart condition, or injection drug use
	2. Fever, temperature >38° C (100.4° F)
	3. Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
	4. Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor
	5. Microbiologic evidence: positive blood culture but does not meet a major criterion as noted above^a or serologic evidence of active infection with organism consistent with IE
^a Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause IE.

Pregnancy and VHD

Figure 10. Anticoagulation of Pregnant Patients With Mechanical Valves

Table 34. Pregnancy and VHD

Recommendations	COR	LOE
Native Valve Stenosis
All patients with suspected valve stenosis should undergo a clinical evaluation and TTE before pregnancy.	I	C
All patients with severe valve stenosis (stages C and D) should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy.	I	C
All patients referred for a valve operation before pregnancy should receive prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy about the risks and benefits of all options for operative interventions, including mechanical prosthesis, bioprosthesis, and valve repair.	I	C
Pregnant patients with severe valve stenosis (stages C and D) should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in the management of high-risk cardiac patients during pregnancy.	I	C
Exercise testing is reasonable in asymptomatic patients with severe AS (aortic velocity ≥4.0 m/s or ΔPmean ≥40 mm Hg, stage C) before pregnancy.	IIa	C
Medical Therapy
Anticoagulation should be given to pregnant patients with MS and AF unless contraindicated.	I	C
Use of beta blockers as required for rate control is reasonable for pregnant patients with MS in the absence of contraindication if tolerated.	IIa	C
Use of diuretics may be reasonable for pregnant patients with MS and HF symptoms (stage D).	IIb	C
ACE inhibitors and ARBs should *NOT*be given to pregnant patients with valve stenosis.	III: Harm	B
Intervention
Valve intervention is recommended before pregnancy for symptomatic patients with severe AS (aortic velocity ≥4.0 m/s or ΔPmean ≥40 mm Hg, stage D).	I	C
Valve intervention is recommended before pregnancy for symptomatic patients with severe MS (MVA ≤1.5 cm2, stage D).	I	C
PMBC is recommended before pregnancy for asymptomatic patients with severe MS (MVA ≤1.5 cm2, stage C) who have valve morphology favorable for PMBC.	I	C
Valve intervention is reasonable before pregnancy for asymptomatic patients with severe AS (aortic velocity ≥4.0 m/s or ΔPmean ≥40 mm Hg, stage C).	IIa	C
PMBC is reasonable for pregnant patients with severe MS (MVA ≤1.5 cm2, stage D) with valve morphology favorable for PMBC who remain symptomatic with NYHA class III-IV HF symptoms despite medical therapy.	IIa	B
Valve intervention is reasonable for pregnant patients with severe MS (MVA ≤1.5 cm2, stage D) and valve morphology not favorable for PMBC only if there are refractory NYHA class IV HF symptoms.	IIa	C
Valve intervention is reasonable for pregnant patients with severe AS (ΔPmean ≥40 mm Hg, stage D) only if there is hemodynamic deterioration or NYHA class III-IV HF symptoms.	IIa	B
Valve operation should *NOT* be performed in pregnant patients with valve stenosis in the absence of severe HF symptoms.	III:Harm	C
Native Valve Regurgitation
All patients with suspected valve regurgitation should undergo a clinical evaluation and TTE before pregnancy.	I	C
All patients with severe valve regurgitation (stages C and D) should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy.	I	C
All patients referred for a valve operation before pregnancy should receive prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy regarding the risks and benefits of all options for operative interventions, including mechanical prosthesis, bioprosthesis, and valve repair.	I	C
Pregnant patients with severe regurgitation (stages C and D) should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in managing high-risk cardiac patients.	I	C
Exercise testing is reasonable in asymptomatic patients with severe valve regurgitation (stage C) before pregnancy.	IIa	C
ACE inhibitors and ARBs should *NOT* be given to pregnant patients with valve regurgitation.	III: Harm	B
Intervention
Valve repair or replacement is recommended before pregnancy for symptomatic women with severe valve regurgitation (stage D).	I	C
Valve operation for pregnant patients with severe valve regurgitation is reasonable only if there are refractory NYHA class IV HF symptoms (stage D).	IIa	C
Valve repair before pregnancy may be considered in the asymptomatic patient with severe MR (stage C) and a valve suitable for repair, but only after detailed discussion with the patient about the risks and benefits of the operation and its outcome on future pregnancies.	IIb	C
Valve operations should *NOT* be performed in pregnant patients with valve regurgitation in the absence of severe intractable HF symptoms.	III:Harm	C
Prosthetic Valves
All patients with a prosthetic valve should undergo a clinical evaluation and baseline TTE before pregnancy.	I	C
All patients with a prosthetic valve should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy.	I	C
TTE should be performed in all pregnant patients with a prosthetic valve if not done before pregnancy.	I	C
Repeat TTE should be performed in all pregnant patients with a prosthetic valve who develop symptoms.	I	C
TEE should be performed in all pregnant patients with a mechanical prosthetic valve who have prosthetic valve obstruction or experience an embolic event.	I	C
Pregnant patients with a mechanical prosthesis should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in the management of high-risk cardiac patients.	I	C
Medical Therapy
Therapeutic anticoagulation with frequent monitoring is recommended for all pregnant patients with a mechanical prosthesis.	I	B
Warfarin is recommended in pregnant patients with a mechanical prosthesis to achieve a therapeutic INR in the second and third trimesters.	I	B
Discontinuation of warfarin with initiation of IV UFH (with an aPTT >2 times control) is recommended before planned vaginal delivery in pregnant patients with a mechanical prosthesis.	I	C
Low-dose ASA (75-100 mg) once per day is recommended for pregnant patients in the second and third trimesters with either a mechanical prosthesis or bioprosthesis.	I	C
Continuation of warfarin during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin to achieve a therapeutic INR is ≤5 mg daily after full discussion with the patient about risks and benefits.	IIa	B
Dose-adjusted LMWH at least 2 times per day (with a target anti-Xa level of 0.8-1.2 U/mL, 4-6 hours postdose) during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is >5 mg daily to achieve a therapeutic INR.	IIa	B
Dose-adjusted continuous IV UFH (with aPTT ≥2 times control) during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is >5 mg daily to achieve a therapeutic INR.	IIa	B
Dose-adjusted LMWH ≥2 times per day (with a target anti-Xa level of 0.8-1.2 U/mL, 4-6 hours postdose) during the first trimester may be reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is ≤5 mg daily to achieve a therapeutic INR.	IIb	B
Dose-adjusted continuous infusion of UFH (with aPTT ≥2 times control) during the first trimester may be reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is ≤5 mg daily to achieve a therapeutic INR.	IIb	B
LMWH should *NOT* be administered to pregnant patients with mechanical prostheses unless anti-Xa levels are monitored 4-6 hours after administration.	III:Harm	B

Surgical Considerations in Patients With CAD

Figure 11. Evaluation and Management of CAD in Patients Undergoing Valve Surgery

Table 35. Surgical Considerations in Patients With VHD

Recommendations	COR	LOE
Evaluation of Coronary Anatomy
Coronary angiography is indicated before valve intervention in patients with symptoms of angina, objective evidence of ischemia, decreased LV systolic function, history of CAD, or coronary risk factors (including men age >40 years and postmenopausal women).	I	C
Coronary angiography should be performed as part of the evaluation of patients with chronic severe secondary MR.	I	C
Surgery without coronary angiography is reasonable for patients having emergency valve surgery for acute valve regurgitation, disease of the aortic sinuses or ascending aorta, or IE.	IIa	C
CT coronary angiography is reasonable to exclude the presence of significant obstructive CAD in selected patients with a low/intermediate pretest probability of CAD. A positive coronary CT angiogram (the presence of any epicardial CAD) can be confirmed with invasive coronary angiography.	IIa	B
Intervention for CAD
CABG or PCI is reasonable in patients undergoing valve repair or replacement with significant CAD (≥70% reduction in luminal diameter in major coronary arteries or ≥50% reduction in luminal diameter in the left main coronary artery).	IIa	C
Intervention for AF
A concomitant maze procedure is reasonable at the time of MV repair or replacement for treatment of chronic, persistent AF.	IIa	C
A full biatrial maze procedure, when technically feasible, is reasonable at the time of MV surgery, compared with a lesser ablation procedure, in patients with chronic, persistent AF.	IIa	B
A concomitant maze procedure or pulmonary vein isolation may be considered at the time of MV repair or replacement in patients with paroxysmal AF that is symptomatic or associated with a history of embolism on anticoagulation.	IIb	C
A concomitant maze procedure or pulmonary vein isolation may be considered at the time of cardiac surgical procedures other than MV surgery in patients with paroxysmal or persistent AF that is symptomatic or associated with a history of emboli on anticoagulation.	IIb	C
Catheter ablation for AF should *NOT* be performed in patients with severe MR when mitral repair or replacement is anticipated, with preference for the combined maze procedure plus MV repair.	III: Harm	B

Table 36. Noncardiac Surgery in Patients With VHD

Recommendations	COR	LOE
Noncardiac Surgery in Patients With VHD
Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS.	IIa	B
Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe MR.	IIa	C
Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AR and a normal LVEF.	IIa	C
Moderate-risk elective noncardiac surgery in patients with appropriate intraoperative and postoperative hemodynamic monitoring may be reasonable to perform in asymptomatic patients with severe MS if valve morphology is not favorable for PMBC.	IIb	C

Applying Classification of Recommendations and Level of Evidence

Size of Treatment Effect

Estimate of Certainty (precision) of Treatment Effect

CLASS I
Benefit >>> Risk
Procedure/Treatment
SHOULD be performed/administered

CLASS IIa
Benefit >> Risk
Additional studies with
focused objectives needed
IT IS REASONABLE
to perform procedure/administer treatment

CLASS IIb
Benefit ≥ Risk
Additional studies with broad objectives needed; additional registry data would be helpful
Procedure/Treatment
MAY BE CONSIDERED

CLASS III
No Benefit or CLASS III
Harm

	Procedure/ Test	Treatment
COR III: No benefit	Not Helpful	No Proven Benefit
COR III: Harm	Excess Cost w/o Benefit or Harmful	Harmful to Patients

LEVEL A
Multiple populations evaluated^a

Data derived from multiple randomized clinical trials or meta-analyses

Recommendation that procedure or treatment is useful/effective
Sufficient evidence from multiple randomized trials or meta-analyses

Recommendation in favor of treatment or procedure being useful/effective
Some conflicting evidence from multiple randomized trials or meta-analyses

Recommendation's usefulness/efficacy less well established
Greater conflicting evidence from multiple randomized trails or meta-analyses

Recommendation that procedure or treatment is not useful/effective and may be harmful
Sufficient evidence from multiple randomized trials of meta-analyses

LEVEL B
Limited populations evaluated^a

Data derived from a single randomized trial or nonrandomized studies

Recommendation that procedure or treatment is useful/effective
Evidence from single randomized trial or nonrandomized studies

Recommendation in favor of treatment or procedure being useful/effective
Some conflicting evidence from single randomized trial or nonrandomized studies

Recommendation's usefulness/efficacy less well established
Greater conflicting evidence from single randomized trial or nonrandomized studies

Recommendation that procedure or treatment is not useful/effective and may be harmful
Evidence from single randomized trial or nonrandomized studies

LEVEL C
Very limited populations evaluated^a

Only consensus opinion of experts, case studies, or standards of care

Recommendation that procedure or treatment is useful/effective
Only expert opinion, case studies, or standard of care

Recommendation in favor of treatment or procedure being useful/effective
Only diverging expert opinion, case studies, or standard of care

Recommendation's usefulness/efficacy less well established
Only diverging expert opinion, case studies, or standard of care

Recommendation that procedure or treatment is not useful/effective and may be harmful
Only expert opinion, case studies, or standard of care

Suggested phrases for writing recommendations:

should
is recommended
is indicated
is useful/effective/beneficial

is reasonable
can be useful/effective/beneficial
is probably recommended or indicated

may/might be considered
may/might be reasonable
usefulness/effectiveness is unknown/unclear/uncertain or not well established

COR III: No Benefit
is not recommended
is not indicated
should not be performed/administered/other
is not useful/beneficial/effective

COR III: Harm
potentially harmful
causes harm
associated with excess morbidity/mortality
should not be performed/ administered/other

Comparative effectiveness phrases^b:

treatment/strategy A
is recommended/indicated in preference
to treatment B

treatment A should be chosen over treatment B

treatment/strategy A is probably recommended/indicated in preference to treatment B

it is reasonable to choose
treatment A over treatment B

A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even when randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

^a Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior MI, history of HF, and prior aspirin use.
^b For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

Abbreviations

2D, 2-dimensional; 3D, 3-dimensional; ΔP, pressure gradient; ACE, angiotensin-converting enzyme; AF, atrial fibrillation; aPTT, activated partial thromboplastin time; AR, aortic regurgitation; ARB, angiotensin-receptor blocker; AS, aortic stenosis; ASA, aspirin; AVA, aortic valve area; AVAi, aortic valve area indexed to body surface area; AVR, aortic valve replacement; BID, twice daily; BP, blood pressure; CABG, coronary artery bypass graft; CAD, coronary artery disease; CKD, chronic kidney disease; CMR, cardiac magnetic resonance; CNS, central nervous system; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; CT, computed tomography; CW, continuous wave; DLCO2, diffusion capacity for carbon dioxide; DSE, dobutamine stress echocardiography; ECG, electrocardiogram; ERO, effective regurgitant orifice; ETT, exercise treadmill test; FEV1, forced expiratory volume in 1 second; GI, gastrointestinal; GDMT, guideline-directed medical therapy; HF, heart failure; HIV, human immunodeficiency virus; ICD, implantable cardioverter-defibrillator; IE, infective endocarditis; IM, intramuscularly; INR, international normalized ratio; IV, intravenous; IVC, inferior vena cava; LA, left atrium; LMWH, low-molecular-weight heparin; LOE, Level of Evidence; LV, left ventricular; LVEF, left ventricular ejection fraction; LVEDD, left ventricular end-diastolic dimension; LVESD, left ventricular end-systolic dimension; LVOT, left ventricular outflow tract; MI, myocardial infarction; MR, mitral regurgitation; MS, mitral stenosis; MV, mitral valve; MVA, mitral valve area; MVR, mitral valve replacement; N/A, not applicable; NVE, native valve endocarditis; NYHA, New York Heart Association; PA, pulmonary artery; PASP, pulmonary artery systolic pressure; PCI, percutaneous coronary intervention; PCWP, pulmonary capillary wedge pressure; PHTN, pulmonary hypertension; PMBC, percutaneous mitral balloon commissurotomy; PO, by mouth; PR, pulmonic regurgitation; PROM, predicted risk of mortality; PVE, prosthetic valve endocarditis; QD, once daily; RA, right atrium; RF, regurgitant fraction; RVol, regurgitant volume; RV, right ventricular; RVH, right ventricular hypertrophy; RVOT, right ventricular outflow tract; Rx, therapy; S. _aureus, Staphylococcus aureus; SC, subcutaneous; T½, half-life; spp, species; STS, Society of Thoracic Surgeons; TA, tricuspid annular; TAVR, transcatheter aortic valve replacement; TEE, transesophageal echocardiography; TR, tricuspid regurgitation; TS, tricuspid stenosis; TTE, transthoracic echocardiography/echocardiogram; TV, tricuspid valve; TVR, tricuspid valve replacement; UFH, unfractionated heparin; VHD, valvular heart disease; VKA, vitamin K antagonist; V_max, maximal velocity

Source

Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM III, Thomas JD. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol 2014;63:e57–185. Copublished in Circulation 2014;129:e521-e643.

Disclaimer

This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care practitioners, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation.

Neither IGC, the medical associations, nor the authors endorse any product or service associated with the distributor of this clinical reference tool.